Renal Failure Without Hemodialysis Is a Risk Factor for Postoperative Complications in Colorectal Cancer Surgery.

Background/Aim: Surgical outcomes of colorectal cancer (CRC) in patients with renal failure (RF) remain to be clarified. The objective of this research was to investigate how RF impacts the surgical outcomes in patients with CRC. Patients and Methods: A retrospective analysis was performed on clinical data from 633 patients who underwent colorectal resection for CRC between January 2017 and December 2021. Outcomes of the patients with and without RF were compared. RF was defined as estimated Glomerular Filtration Rate less than 30. Results: Forty-five (7%) patients with RF were identified. RF was a significant risk factor for postoperative complications after colorectal cancer surgery (odds ratio=2.19, 95% confidence interval=1.08-4.42, p=0.0284). The patients with RF had significantly more comorbidity (p=0.016), and higher American Society of Anesthesiologists physical status (p<0.01). Hemoglobin level (p<0.01) and PNI (p<0.01) were significantly lower in those with RF. Postoperative complications were significantly higher (p=0.016), and the postoperative hospital stay was significantly longer (p<0.01) among patients with RF compared to those without RF. Patients with RF, excluding those undergoing hemodialysis, had significantly more complications compared to those without RF (p=0.004). Conclusion: Careful attention should be paid to perioperative management in RF colorectal cancer patients.

Clinicopathological Features of Remnant Gastric Cancer (RGC): Detection of RGC after Five Years of Follow-Up Was Associated with a Poor Prognosis.

The purpose of this study was to evaluate the clinicopathological features and prognosis of patients who underwent surgery for remnant gastric cancer (RGC) during/after the regular five-year follow-up period after initial distal gastrectomy for gastric cancer that is recommended by the Japanese gastric cancer treatment guidelines. Between January 2007 and December 2017, 40 patients underwent surgery for RGC after distal gastrectomy. Twenty-eight of the 40 patients underwent initial gastrectomy for cancer. We divided the 28 patients into two groups: patients who were diagnosed with RGC during/after the five-year follow-up period after initial gastrectomy, and analyzed their retrospectively collected data. Among the 28 patients, 15 patients were diagnosed with RGC within five years and 13 patients were diagnosed with RGC after five years. There were significant differences in the reconstruction of the initial operation, curative resection, pathological depth of the tumor, and pathological stage of the two groups. Multivariate analyses revealed that the interval between initial gastrectomy and RGC and the pathological TNM stage were significant risk factors for shorter cancer-specific survival. Kaplan-Meier analyses demonstrated that patients with RGC after the five-year follow-up period had a significantly worse prognosis in terms of cancer-specific survival than those who developed RGC within five years. This study suggested surveillance by using the annual endoscopy might be necessary beyond the initial five-year period for patients who underwent gastrectomy for gastric cancer.

[Two Cases of Hepatic Encephalopathy after Chemotherapy for Metastatic Colorectal Cancer].

We reported 2 cases of hepatic encephalopathy after chemotherapy for advanced colorectal cancer. Case 1: A 49-year-old male was diagnosed advanced sigmoid colon cancer with peritoneal dissemination, multiple liver metastasis and multiple osseous metastasis. After resection of primary lesion, we administered mFOLFOX6 plus bevacizumab combination therapy. He was in comatose(Japan coma scale 200)3 days after 2 courses of administration of this regimen. Case 2: A 57-year-old female was diagnosed advanced rectal cancer with multiple huge liver metastasis and multiple osseous metastasis. We administered mFOLFOX6 plus panitumumab combination therapy. She was in comatose(Japan coma scale 100)3 days after 10 courses of administration of this regimen. In both cases, radiographic imaging showed no abnormal sign and blood examination revealed a high level of serum ammonia. We diagnosed their disturbance of consciousness as a symptom of hepatic encephalopathy. Branched-chain amino acid infusion rapidly improved disturbance of consciousness. We must consider the symptom, hepatic encephalopathy in patients receiving chemotherapy for advanced colorectal cancer.

[A Case of Successful Management of Postoperative Chylous Ascites by Combination Therapy with Octreotide and Etilefrine].

We have report a case of an 81-year-old woman who underwent distal pancreatectomy for pancreatic body cancer. Chy- lous ascites with high triglyceride(TG)level, 201mg/dL, occurred on postoperative day 2. Continuous drainage and conservative management, such as low fat diet, fasting, total parental nutrition, and octreotide monotherapy, could not resolve the problem. Successful treatment was achieved using subcutaneous octreotide injection and intravenous etilefrine infusion without any adverse side-effect. These medications were able to cause smooth muscle contraction in the thoracic duct, and also to reduce chyle flow. The amount of drainage decreased and the TG level was restored to 66mg/dL. The drainage tube was removed on postoperative day 22, 5 days after the start of both octreotide and etilefrine. This combination therapy with octreotide and etilefrine would be one of effective and safety treatment for management of postoperative intractable chylous ascites.

Laparoscopic Resection of a Jejunal Inflammatory Fibroid Polyp that Caused Occult Gastrointestinal Bleeding, Diagnosed via Capsule Endoscopy and Double-Balloon Enteroscopy: A Case Report.

An inflammatory fibroid polyp (IFP) is a mesenchymal tumor of the gastrointestinal tract. IFPs in the small intestine are the most frequently detected with symptoms, such as abdominal pain and tarry stool due to intussusception. Accordingly, few studies have reported jejunal IFP as a cause of occult gastrointestinal bleeding (OGIB) diagnosed via both of capsule endoscopy (CE) and double-balloon enteroscopy (DBE). A 68-year-old woman presented with a progression of anemia and a positive fecal occult blood test result. Esophagogastroduodenoscopy and total colonoscopy findings were unremarkable. CE revealed a tumor with bleeding in the jejunum. DBE also revealed a jejunal polypoid tumor. Bleeding from the tumor seemed to have caused anemia. The patient underwent partial laparoscopic resection of the jejunum, including resection of the tumor. The tumor was histopathologically diagnosed as IFP. To our knowledge, this is the first reported case of laparoscopic resection of jejunal IFP with OGIB diagnosed via CE and DBE preoperatively.

[A Patient Underwent Pancreaticoduodenectomy with Reconstruction of Replaced Right Hepatic Artery].

A 78 year-old man was diagnosed as a pancreatic cancer in department of gastroenterology in our hospital. Enhanced computed tomography demonstrated an aberrant right hepatic artery(ARHA)arising from superior mesenteric artery(SMA). We conducted sub-stomach preserving pancreaticoduodenectomy(SSPPD- II A-1). As the preoperative diagnosis, right hepatic artery(RHA)was arising from SMA and running through the tumor, and we resected the ARHA with the tumor and reconstructed RHA to gastroduodenal artery(GDA). Pathological diagnosis was non invasive tumor with neither lymph node metastasis nor invasion of the vasculature. We report a case of the patient underwent pancreaticoduodenectomy with reconstruction of aberrant right hepatic artery.

Safety of laparoscopic distal gastrectomy for gastric cancer when performed by trainee surgeons with little experience in performing open gastrectomy.

PURPOSE: This study aimed to evaluate the surgical outcomes and clinical safety of laparoscopic distal gastrectomy (LDG) when performed by trainee surgeons with little prior experience in performing open gastrectomy, under the guidance of trainer surgeons. METHODS: From January 2008 until March 2015, 17 trainee surgeons and 5 trainer surgeons performed LDGs to treat 371 patients with clinical stage T1-T3 gastric cancer. Of these patients, 140 and 231 underwent LDG performed by trainee surgeons and trainer surgeons, respectively. We retrospectively analyzed the surgical outcomes of the two groups. RESULTS: Trainee surgeons required significantly longer operation times than the trainer surgeons, with respective mean operation times of 262 and 223 min (p < 0.001). However, the mean blood loss volumes, average numbers of retrieved lymph nodes, postoperative complications, and postoperative hospital stay lengths did not differ significantly between LDGs performed by trainee surgeons and trainer surgeons. CONCLUSIONS: The study findings suggest that, under the guidance of trainer surgeons, trainee surgeons with little experience with open gastrectomy and even without prior experience with LDG can perform radical surgeries safely.

[A Resected Case of the Vaginal Metastasis from Rectal Cancer].

The vaginal metastasis from colorectal cancer has rarely been reported. Here, we report a resected case of the vaginal metastasis from rectal cancer. A 51-year-old woman underwent radical hysterectomy and bilateral oophorectomy for uterus cancer. Five years after the operation, vaginal tumor was observed during an internal examination. Biopsy was positive for adenocarcinoma. Enhanced computed tomography demonstrated the wall thickening of the lower rectum and the mass of 20 mm at the inferior lobe of the left lung. Colonoscopy revealed the wall thickening of the lower rectum, and biopsy indicated a diagnosis of rectal cancer. We performed abdominoperineal resection and partial resection of the vagina. Pathological examination confirmed the vaginal metastasis from the rectal cancer.

[Experiences of Colonic Stents in Patients with Colonic Stenosis Due to Peritoneal Dissemination of Gastric Cancer].

Stoma is a treatment option often adopted for large bowel obstruction accompanying peritoneal dissemination of gastric cancer, but the invasiveness of this intervention can be an issue for patients with limited prognosis and reduced quality of life. In our hospital, colonic stenting for bowel obstruction due to peritoneal dissemination from gastric cancer was performed for 7 consecutive patients. Oral ingestion became possible in 5 cases, and colonic stent was considered a useful treatment choice for appropriate cases.

[A Case Report of Inguinal Malignant Lymphoma after Surgery for Hepatocellular Carcinoma].

An 81-year-old woman was followed up for hepatitis C from 1994. Sheh ad a previous history of hypertension and appendicitis. In October 2014, the patient underwent subsegmentectomy(S8)and cholecystectomy for hepatocellular carcinoma (HCC)(T2N0M0, Stage II ). From December 2015, the patient had taken ledipasvir-sofosbuvir orally for hepatitis C virus (HCV). In January 2016, we confirmed HCV-RNA shade transformation. In September 2016, enhanced CT showed a mass in theright lower quadrant of her abdomen. Shehad a hard 3 cm mass in thesameplaceon physical exam. PET-CT showed no significant abnormality except for the mass in the right lower quadrant of her abdomen. Therefore, we identified the differential diagnosis as a lymph node metastasis of HCC, an abdominal wall primary tumor, or a malignant lymphoma. We resected theinguinal malignant lymphoma to confirm thediagnosis. Examination of tissuefrom theinguinal malignant lymphoma indicated diffuselargeB -cell lymphoma. We report an interesting case of an inguinal malignant lymphoma in a patient with chronic HCV who had experienced hepatectomy.

[A Case of Unresectable Advanced Gastric Cancer Treated with Palliative Radiation Therapy for Massive Bleeding].

The patient was a 77-year-old man. He was diagnosed with Stage IV gastric cancer with pancreatic invasion and pyloric stenosis. After gastrojejunostomy, S-1 monotherapy was started. Melena and fatigue appeared 2 months after chemotherapy, and Grade 3 anemia was confirmed. Palliative radiotherapy of 30 Gy in 10 Fr was administered to control bleeding from the lesion. The progression of anemia stopped and outpatient chemotherapy became possible. Palliative radiotherapy for persistent bleeding from unresectable advanced gastric cancer is considered an effective treatment option to control bleeding.

[A Colorectal Cancer with Invasive Micropapillary Carcinoma].

A 76-year-old woman with bloody stool visited a nearby hospital. Colonoscopy showed a type 1 tumor in the rectum, and the biopsy indicated moderately differentiated adenocarcinoma. She was referred to our hospital. Abdominal contrast-enhanced CT did not show swollen lymph nodes in the regional nodes or distant metastases. Laparoscopic lower anterior resection was performed. Histopathological examination indicated pT1b, pN3, ly3, and v1, fStage III b, which had a partial invasive micropapillary carcinoma(IMPC)component of papillary adenocarcinoma. Although she received postoperative adjuvant chemotherapy, she died of a thromboembolism with paraneoplastic syndrome 20 months after the operation. IMPC has a high incidence of lymphatic invasion and lymph node metastases. IMPC is rare in cases of colorectal cancer and it is important to accumulate and investigate colorectal cancer patients with IMPC.

[Anorectal Malignant Melanoma Is a Very Rare Disease and Has a Poor Prognosis].

We performed abdomino-perineal-resection(APR)on 2 cases of anorectal malignant melanoma. The first case was a 70- year-old woman suffering from bloody stool. Colonoscopy showed a black tumor in the rectum. Biopsy revealed a malignant melanoma. A CT scan showed multiple lung metastases and liver metastasis. She underwent surgery for the purpose of bleeding control, but died shortly thereafter because her liver and lung metastases had worsened. The second case was a 43- years-old man suffering from bloody stool. He had a black type 3 tumor in the rectum. A biopsy revealed malignant melanoma. A CT scan showed lateral lymph node swelling. He underwent APR with right side-lateral dissection. An established treatment for anorectal malignant melanoma has not been agreed upon and it is controversial. We experienced 2 cases that underwent surgery and we report them along with relevant information from the literature.

[Surgical Outcome of Palliative Surgery for Gastric Cancer Patients with Bowel Obstruction Due to Peritoneal Dissemination].

A retrospective cohort analysis was performed for 21 consecutive patients who underwent palliative surgery for bowel obstruction due to peritoneal metastasis from gastric cancer. Surgical site infection occurred in 5 of 21 patients, but there were no severe(Clavien-Dindo Grade III or higher)complications, and symptoms of bowel obstruction were improved in 20 of 21 patients. The median survival time was 6.6 months. The survival rate was significantly worse for patients in modified Glasgow prognostic score(mGPS)group D compared with those in mGPS group non-D(p=0.0001). Surgery for malignant bowel obstruction was feasible and effective for palliation.

[Treatment Experience with Sorafenib for Lung Metastases of Hepatocellular Carcinoma Complicated with Interstitial Pneumonia].

A 74-year-old man was diagnosed with hepatocellular carcinoma(HCC; S4/8)and underwent anterior segment resection of the liver in 2015. He was hospitalized with a wound infection 2 months after surgery. On the 8th hospital day he complained of respiratory discomfort. A CT showed multiple lung metastases and a ground-glass appearance in both lungs. We diagnosed interstitial pneumonia with metastatic lung tumors. Steroid therapy was performed for the interstitial pneumo- nia(prednisolone 1,000mg/day×3 days), and sorafenib therapy was initiated for the metastatic lung cancer(starting from 200mg/day to 800mg/day). The prednisolone improved his symptoms. The lung metastatic tumors shrunk by the 36th hospital day after the CT. However, he developed difficulty in breathing again on the 58th hospital day, and again showed a ground-glass appearance in both lungs by CT. We thought it was drug-induced interstitial pneumonia and we discontinued oral sorafenib. He underwent steroid pulse therapy, but his symptoms did not improve and he died.

[Pathological Complete Response in a Case of Multiple Liver Metastases from Rectal Cancer Treated with XELOX plus Bevacizumab(Bev)Therapy].

The patient was a 56-year-old woman who had synchronous multiple liver metastases and underwent laparoscopic-assisted high anterior resection for rectal cancer. According to the Japanese classification of colorectal carcinoma(8th edition), the tumor was considered to be pStage IV (pT4bN2M1a[H3]). Following resection of the primary tumor, she received XELOX plus bevacizumab(Bev)therapy. After 5 courses, the tumors were markedly reduced in size. According to the RECIST criteria, the tumor response was determined to be a partial response(-44%). Therefore, on the basis of the morphologic response criteria, the patient had Group 1 disease. Because the chemotherapy seemed to be effective, we performed partial hepatectomies. Histologically, no cancer cells were detected in any of the resected tumors. After the partial hepatectomies, she received no additional chemotherapy. Her CEA levels decreased to a normal range and no tumor recurrence was detected over 2 and a half years. XELOX plus Bev therapy may be effective for unresectable multiple liver metastasis from rectal cancer.

[Clinical Experience with Nutrition and Anticoagulation Therapy for a Patient with a 30 cm Residual Jejunum].

Patients with short bowel syndrome experience malabsorption and digestive disorders. They are unable to maintain adequate nutrition by the oral or enteral route alone, and their requirements for liquids, electrolytes, nutrients, microelements, vitamins, etc., are not completely met. Managing the nutritional needs of these patients is important. Another concern is these patients' inability to absorb medication, because the small intestine that is shortened in short bowel syndrome is the principal site of drug absorption. Here, we report a case of a 74-year-old woman with a 30 cm residual jejunum after surgery for acute occlusion of the superior mesenteric artery and the clinical management of nutrition and anticoagulant medication in this patient.

[Endoscopic Stent Placement to Alleviate Afferent Loop Syndrome Following Recurrence of Pancreatic Cancer].

We report a case of endoscopic stent placement to alleviate afferent loop syndrome following recurrence of pancreatic cancer. A 73-year-old man who had undergone pancreatic duodenectomy with portal vein resection for pancreatic cancer had developed a local recurrence and was treated with chemotherapy. He developed a high-grade fever and general fatigue, and laboratory data revealed anemia and a high inflammatory reaction; therefore, he was admitted to our hospital. CT scans revealed intestinal stenosis and upper dilatation, known as afferent loop syndrome, caused by the recurrence. We safely implanted a metallic stent(non-covered Niti-S stent, Century Medical, Inc.)at the point of intestinal stenosis using a double balloon endoscope. As the stent was adequately expanded and the afferent loop syndrome was relieved, the patient was discharged with a better quality of life and there were no complications associated with the stent until he died 6 months later.

[A Case of Metastatic Colorectal Cancer Refractory to Standard Chemotherapies Treated with TAS-102 with Bevacizumab].

A 51-year-oldwoman with lung, liver, andd istant lymph node metastases from sigmoidcolon cancer was treatedusing TAS-102 with bevacizumab as fourth-line chemotherapy. There was a 35%decrease in the size of target lesions after the first 4 cycles of therapy, and disease control has been maintained for 9 months. The only Grade 3 or worse adverse event experiencedwas neutropenia. In patients with refractory colorectal cancer, the combination of TAS-102 with bevacizumab might be an effective andsafe treatment.

[A Case of Appendiceal Mucinous Cystadenoma Treated Using Laparoscopic Appendectomy].

A 73 year-old woman who was treated for breast cancer and visited our hospital regularly was suspected of having a mucinous cystadenoma of the appendix. Malignancy could not be determined using abdominal computed tomography, magnetic resonance imaging, or colonoscopy. Even if mucinous cystadenoma is benign, there is the possibility that the tumor will rupture, discharge its contents, and cause pseudomyxoma peritonei. We performed laparoscopic appendectomy. According to the histopathological results, the tumor was diagnosed as a low grade appendiceal mucinous neoplasm. We report a case of mucinous cystadenoma of the appendix treated using laparoscopy-assisted appendectomy and discuss the case with literature reviews.